Any surgeon treating a patient with adrenal disease should be a member of a multi-disciplinary team involving dedicated specialists, including an endocrinologist, anaesthetist, radiologist, intensivist and geneticist. In an era of epidemic numbers of adrenal incidentalomas, great care must be taken to determine not only the endocrine diagnosis, but also the benefits (if any) of adrenal surgery. Finally, the surgeon must be competent in both minimally invasive and gross resectional surgical techniques and know when to adopt these two very different surgical approaches.

Increasing consumption of sugar-sweetened beverages has occurred in parallel with the increasing prevalence of chronic kidney disease (CKD) in the US. Consumption of sugar-sweetened beverages, particularly with fructose, has been shown to play an important role in the pathogenesis of obesity, diabetes, hypertension, hyperuricemia, and nephrolithiasis, all of which are risk factors for CKD. However, the direct role of sugarsweetened beverages in the progression of CKD remains unclear. To date, five epidemiologic studies have examined the association between sugar consumption and kidney outcomes, with two showing statistically significant positive associations between higher sugar intake and adverse kidney outcomes. Even though the direct causal relationship between sugar-sweetened beverages and CKD has not been definitely established, it is advisable to counsel individuals with CKD and those at risk for CKD to limit the intake of sugar-sweetened beverages in light of its known detrimental effects on CKD risk factors.

Choosing the appropriate glucose-lowering therapy for the optimal management of type 2 diabetes is always challenging. Existing guidelines either do not offer any recommendations as to which particular drug to use as second- or third-line therapy, or make the issue too confusing for a primary care physician to follow. We suggest a simple, metabolic fulcrum-based approach, which classifies persons with type 2 diabetes as being eubolic, as being predominantly catabolic, or as having “maladaptive anabolism.” This metabolic triage, performed using phenotypic features, with or without supporting investigations, allows the rational choice of therapy, which helps achieve glycemic targets in a more efficient manner.

Refractory, or ‘difficult to control,’ diabetes is a commonly encountered condition in specialist practice. This editorial describes the characteristics of people with diabetes who are unable to achieve optimal glycemic control, despite aggressive drug therapy. It reflects upon the importance of bidirectional communication between patient and physician, and highlights the need for systematic history taking, empathic listening, and therapeutic patient education. The editors call for practicing ‘diabetes therapy by the ear,’ in conjunction with evidence-based pharmacological therapy, to help reduce the prevalence of refractory diabetes.

Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by destruction of insulin-producing β cells in the pancreas. The incidence of T1D is increasing dramatically, and the prevalence has doubled in the last 2 decades, further increasing the morbidity and mortality associated with the disease. T1D is now predictable with the measurement of antibodies directed against β cell proteins. Islet autoantibodies (IAs) are detectable from the peripheral blood months to years before clinical diagnosis. With the presence of two or more antibodies, the risk for developing T1D is nearly 100 % given enough time. Targeted screening for T1D risk has been carried out in first-degree relatives and those with a significant genetic risk. However, more than 85 % of individuals who are diagnosed with T1D do not have a family history. In light of the predictability of T1D and recent advances in IA measurement, general population screening is on the horizon. We provide an overview of the history of general population screening and discuss the rationale for and arguments against screening the general population for T1D risk.

The worldwide rise in body weight has reached epidemic proportions and this has serious public health consequences. Despite the universal recognition of this problem, its causes are still debated: some attribute it to excess caloric intake; others blame a lack of physical activity (PA); some implicate specific changes to micro- and macro-nutrients. During the past century, government health agencies have developed guidance on healthy eating. These, along with advances in agriculture and food manufacturing, have largely eliminated nutrient deficiencies and helped reduce the consumption of fat. Over the past 60 years, however, technological advances and shifts in the types of occupations prominent in industrialized as well as developing countries have resulted in well-documented decreases in energy expenditure. Energy intake must be balanced with energy expenditure in order to prevent weight gain, and there is increasing evidence that this balance must be at a relatively high level of energy flux. A program that was started in São Paulo in 1996 known as ‘Agita’ has sought to motivate populations to engage in small amounts of physical exercise daily to tackle growing obesity levels. This multi-agency initiative is one example of how to successfully increase exercise within a community and scale both within (e.g. all states in Brazil) and across many nations. Reducing caloric intake in whole populations is challenging especially at relatively low levels of energy expenditure, and evidence suggests that there is a critical energy flux threshold for regulating intake to achieve energy balance. Increasing PA, however, may be more achievable than reducing intake. Activity raises caloric expenditure and can offset excess intake. The implementation of programs to achieve greater PA is therefore vital if the worldwide rise in body weight is to be halted, while we also need to implement programs to help people eat smarter.

Clinical assessment of glycemic variability (GV) attempts to measure factors that may be contribute to tissue damage and the complications of diabetes that are not measured in glycosylated hemoglobin (HbA1C). Physicians managing patients with diabetes immediately understand the concept of GV; however, how it is assessed in clinical research trials and whether it has any predictive power in patients with type 1 diabetes is controversial and uncertain. This review is intended to help the reader understand the various GV metrics currently being reported in the literature, the potential mechanisms by which GV may contribute to the pathogenesis of the long-term complications of diabetes, and, finally, the evidence that reducing GV is beneficial to patients with type 1 diabetes.

Long-term pharmacologic strategies that may be used in conjunction with lifestyle changes to address the obesity epidemic have, until recently, been an unmet clinical need. Interestingly, pharmacologic interventions to date have not specifically focused on modifying the behavioral aspects of eating. Food intake is influenced by multiple pathways, including the homeostatic regulation of energy balance controlled by the hypothalamus and the mesolimbic reward system, dysregulation of which can lead to reward eating, food craving, and overconsumption of food. A growing body of evidence suggests that targeting the reward system can be a successful intervention for obesity management. Sustained-release naltrexone/bupropion is a novel combination therapy that targets both the hypothalamic melanocortin system and the reward system. In clinical trials, naltrexone/bupropion has been associated with sustained and clinically meaningful weight loss together with beneficial effects on eating behavior and improvements in cardiometabolic factors. Craving and control of food intake were also measured and correlated with improved outcome.

Treating pregnant women with anti-thyroid drugs that have known teratogenic effects continues to present clinicians with multiple concerns.

Safe and effective therapies for type 2 diabetes are needed to reduce the burden of late complications and costs associated with this chronic disease. Hypoglycaemia and body weight gain are side effects and limitations of the therapy with insulin and/or sulphonylureas. Recently, the combination of glucagon-like peptide-1 (GLP-1) receptor agonists and insulin has become available, which is associated with good efficacy and less risk for hypoglycaemia and weight gain. This editorial discusses the strategies to escalate treatment in type 2 diabetes in view of this novel combination and discusses its placement within the therapeutic algorithm of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Recent developments to simplify this combination therapy are also dealt with.